Inequalities in risk stratification and management of non-communicable diseases
Authors: Ana Olga Mocumbi
Journal: The Lancet Global Health (2023)

Around 80% of all cardiovascular deaths occur in low-income and middle-income countries (LMICs).1HOGlobal status report on noncommunicable diseases 2010. World Health Organization, Geneva2011Google Scholar Detection of people at risk of cardiovascular events is therefore important. The standardised WHO package of essential noncommunicable disease interventions for primary care (PEN) includes detection of hypertension and testing for diabetes and hypercholesterolaemia in adults. Laboratory testing is therefore a key element of cardiovascular risk stratification and should be used both in population-based surveys and in clinical practice. However, in LMICS, there are major gaps in capacity to diagnose, prevent, and control non-communicable diseases. Low availability of essential medicines and qualified health-care professionals, poor recording and miscalculation of cardiovascular risk score, suboptimal recording of patient information, and loss to follow-up were the key challenges reported in various PEN implementation schemes.2Tripathy JP Mishra S How effective was implementation of the package of essential non-communicable disease (PEN) interventions: a review of evidence?.Diabetes Metab Syndr. 2021; 15102266Crossref Scopus (1) Google Scholar In a 2021 review3Albelbeisi AH Albelbeisi A El Bilbeisi AH Taleb M Takian A Akbari-Sari A Public sector capacity to prevent and control of noncommunicable diseases in twelve low- and middle-income countries based on WHO-PEN standards: a systematic review.Health Serv Insights. 2021; 14 (1178632920986233)Google Scholar of 304 health facilities in the public sector in 12 LMICs, readiness index scores ranged from 13·5% to 51·0% for essential medicines, 0·0% to 59·4% for diagnostic investigations, and 29·2% to 51·2% for basic equipment (a score of 100% corresponds to having all items recommended by WHO PEN to treat non-communicable diseases). In The Lancet Global Health, Sophie Ochmann and colleagues4Ochmann S von Polenz I Marcus M-E et al.Diagnostic testing for hypertension, diabetes, and hypercholesterolemia in low-income and middle-income countries: a cross-sectional study of data for 994 185 individuals from 57 nationally representative surveys.Lancet Glob Health. 2023; 11: e1363-e1371Google Scholar report diagnostic testing performance of the health systems of 56 LMICs for three major cardiovascular risk factors (hypertension, diabetes, and hypercholesterolaemia). Their analysis was based on a harmonised individual-level dataset of nearly a million individuals drawn from nationally representative surveys and assessed adherence to the WHO PEN diagnostic testing guidelines. A large gap was identified between people who fulfilled the criteria for testing and the people who were actually tested. For the three risk factors, 84·4–87·7% of all respondents had never been tested. Importantly, people with at least secondary education and people in the highest wealth quintile were significantly more likely to be tested than those with less than primary education and those in the lowest wealth quintile, respectively, suggesting that sociodemographic factors rather than risk-factor-based testing recommendations determined whether individuals were screened. Risk awareness and screening can be used as indicators of access to care.5Modesti PA Perruolo E Parati G Need for better blood pressure measurement in developing countries to improve prevention of cardiovascular disease.J Epidemiol. 2015; 25: 91-98Crossref PubMed Scopus (0) Google Scholar In LMIC health systems, patients’ non-adherence to regularly screening and competing demands on physicians’ time contribute to poor risk factor control and outcomes. The high prevalence of people with low socioeconomic status in LMICs contributes to disparities in control of cardiovascular risk factors between high-income countries and LMICs.6Lu Y Wang P Zhou T et al.Comparison of Prevalence, awareness, treatment, and control of cardiovascular risk factors in China and the United States.J Am Heart Assoc. 2018; 7e007462Crossref Scopus (108) Google Scholar For instance, the lowest global levels of awareness, treatment, and control of hypertension—arguably the least complex risk factor to screen for, diagnose, and manage among those assessed by Ochmann and colleagues—are in southern Africa and south Asia, where the largest proportion of the world's poorest billion people lives.6Lu Y Wang P Zhou T et al.Comparison of Prevalence, awareness, treatment, and control of cardiovascular risk factors in China and the United States.J Am Heart Assoc. 2018; 7e007462Crossref Scopus (108) Google Scholar, 7Bukhman G Mocumbi AO Atun R et al.The Lancet NCDI Poverty Commission: bridging a gap in universal health coverage for the poorest billion.Lancet. 2020; 396: 991-1044Summary Full Text Full Text PDF PubMed Scopus (121) Google Scholar, 8Kayima J Wanyenze RK Katamba A Leontsini E Nuwaha F Hypertension awareness, treatment and control in Africa: a systematic review.BMC Cardiovasc Disord. 2013; 13: 54Crossref PubMed Scopus (0) Google Scholar Even within LMICs, higher education and literacy levels, health insurance coverage, and access to private care are associated with better hypertension control.8Kayima J Wanyenze RK Katamba A Leontsini E Nuwaha F Hypertension awareness, treatment and control in Africa: a systematic review.BMC Cardiovasc Disord. 2013; 13: 54Crossref PubMed Scopus (0) Google Scholar Low availability of essential diagnostics and interventions in public health facilities, low affordability of diagnostics and medicines, and poor coverage by health insurance systems are barriers to care that could explain Ochmann and colleagues’ findings.4Ochmann S von Polenz I Marcus M-E et al.Diagnostic testing for hypertension, diabetes, and hypercholesterolemia in low-income and middle-income countries: a cross-sectional study of data for 994 185 individuals from 57 nationally representative surveys.Lancet Glob Health. 2023; 11: e1363-e1371Google Scholar These barriers increase the risk of catastrophic out-of-pocket expenses—eg, when an individual is faced with funding the screening and diagnosis of diabetes and hypercholesterolaemia. In most LMICs, the cost of minimal follow-up with laboratory tests and treatments to reduce the burden of risk factors usually exceeds the resources available at both the individual and societal level. Often, patients have to travel long distances to access health facilities, which further increases costs and hinders risk factor control. Innovation and pragmatic approaches are need to promote universal access to diagnosis of, and interventions for, common cardiovascular risk factors in LMICs, to reduce large disparities in outcomes compared with high-income countries.9Jilani MH Javed Z Yahya T et al.Social determinants of health and cardiovascular disease: current state and future directions towards healthcare equity.Curr Atheroscler Rep. 2021; 23: 55Crossref PubMed Scopus (28) Google Scholar Although non-laboratory-based models that replace cholesterol testing with BMI measurement showed promising results in predicting cardiovascular events in some populations,10Gaziano TA Young CR Fitzmaurice G Atwood S Gaziano JM Laboratory-based versus non-laboratory-based method for assessment of cardiovascular disease risk: the NHANES I Follow-up Study cohort.Lancet. 2008; 371: 923-931Summary Full Text Full Text PDF PubMed Scopus (266) Google Scholar they might not be applicable worldwide. The unique profile of risk in LMICs—characterised by poverty and multimorbidity (including endemic infections, malnutrition, hereditary anaemias, environmental hazards, and exposure to various toxins)—add complexity to risk assessment, in a context of a scarcity of qualified health providers. Multimorbidity usually increases the cost and burden of risk assessment for patients, health systems, and communities, increasing the risk of catastrophic spending and poverty. Access to screening, stratification, and management of cardiovascular risk factors has been hampered by socioeconomic determinants of health in LMICs. Government and funders need to commit to increasing access to diagnosis and interventions to control these risk factors, including in remote rural communities, to promote equity and social justice. Inaction could perpetuate the vicious cycle of poverty and chronic disease in LMICs and hamper efforts to achieve the Sustainable Development Goals by compromising progress towards alleviation of poverty and provision of universal health coverage. I declare no competing interests. Diagnostic testing for hypertension, diabetes, and hypercholesterolaemia in low-income and middle-income countries: a cross-sectional study of data for 994 185 individuals from 57 nationally representative surveysOur study shows opportunities for health systems in LMICs to improve the targeting of diagnostic testing for cardiovascular risk factors and adherence to diagnostic testing guidelines. Risk-factor-based testing recommendations rather than sociodemographic characteristics should determine which individuals are tested. Full-Text PDF Open Access